Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: The NHS doesn’t need more “restructuring”

BMJ 2019; 366 doi: (Published 03 July 2019) Cite this as: BMJ 2019;366:l4451
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}
    Follow David on Twitter: @mancunianmedic

People are fond of saying that the NHS needs some sort of radical overhaul. On 25 June the Conservative leadership candidate Boris Johnson said that it “needs reform,” as it was “not getting the kind of support and indeed the kind of changes and management that it needs.”1 The perils of constant structural reorganisation have been described beautifully in the Nuffield Trust’s Doomed to Repeat report.2 Politicians and lobbyists never learn.

Weeks before, Kate Andrews, associate director of the Institute of Economic Affairs (IEA), had asserted on Jeremy Vine’s BBC show that the NHS was falling behind other systems and needed structural reform. The link was tweeted by the IEA, saying that “we really, really, really need to structurally reform the NHS.”3

Andrews has made numerous broadcast appearances making the same arguments, but the IEA’s ideological opposition to the NHS model,4 its small state, pro-market view of public services, and its funding sources5 are rarely mentioned on air.

Although she called for restructuring, she specifically meant changing the NHS model of funding and provision. She highlighted that, in some selected population or disease specific outcomes, the NHS performs worse than some other EU countries. This is a fair comment, based on some international comparisons updated yearly by the Organisation for Economic Co-operation and Development (OECD)6 and other research groups.789 But data can be cited selectively to suit most ideological lines. And population health outcomes are influenced not just by healthcare but by social policy and non-medical determinants of health: inequalities, welfare, housing, education, tobacco, alcohol and food pricing, and regulation.1011

Funding and provision models

Andrews’s main point was that the NHS model of funding and provision has become a sacred cow, taboo in a serious political debate or public conversation. She argued that several other nations with different funding and provision models still provided universal, largely charge-free or reimbursable services to the population, often with better outcomes.

For her on-air comparison, however, she didn’t pick other OECD countries that spend about the same as or less than the UK on healthcare. The 2017 OECD health statistics show that the countries she did cite (France, Germany, and Switzerland) all spend a considerably higher percentage of gross domestic product and more money per capita than the UK.12 These differences have been sustained over many years.

Those nations also employ more doctors and nurses per 1000 population and have more beds.11 They also use a so called “Bismarckian” funding model based on health insurance through individuals and employers, not the central or regional state.13 Germany and Switzerland in particular have very diverse, competitive, and consumerist service provision and a higher proportion of healthcare privately funded out of pocket. Meanwhile, the Commonwealth Fund repeatedly ranks the UK highly for equity of access and for people not being denied care for fear of cost.

I don’t disagree with Andrews that our outcome data for some conditions are mediocre; that there’s more than one way to provide a fairly universal, decent health system; or that the systems she cites have managed to avoid lurching from one high profile funding crisis to another. However, she did not choose to cite systems far closer to our own tax funded, single payer, “Beveridge” model, such as those in Scandinavia, Spain, or New Zealand. She didn’t make the argument that, if we made a political decision to fund the NHS to the same levels as France or Germany, the crisis narrative might disappear. As Nigel Edwards of the Nuffield Trust has pointed out, it’s a myth that no countries want to copy or learn from the NHS model.14

Make no mistake: the IEA would like to see a market in which multiple private sector health insurers and health providers derive profit from public healthcare provision. It certainly doesn’t want increased government funding of services, and it wants to see more responsibility devolved to individual citizens for their own health and healthcare.

Our traditional political parties have been reluctant to go down this route because it would be unpopular with many voters. The public is generally supportive of the NHS, its funding model, and its provision of care, free at the point of use and based on need.15

Of course, the NHS could be better—but this is equally possible within a tax funded, state provided system if it is adequately resourced and staffed. It doesn’t need a major restructure, or a change in its model of funding or provision, to achieve that.



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